CMS releases 2015 Proposed Physician Fee and Clinical Laboratory Fee Schedules

CMS recently released the Proposed Rules for the 2015 Physician Fee Schedule (PFS) and Clinical Laboratory Fee Schedule (CLFS) and the news is actually pretty good for pathology.

·Prostate biopsy codes

CMS is again changing the manner with which prostate biopsies will be coded and reimbursed (pages 89-91 of the Proposed Rule), and is proposing to use only code G0416, regardless of the number of biopsies submitted. In addition to the coding changes, CMS has identified G0416 as a potentially misvalued code and is seeking public comment on “appropriate work RVUs, work time, and direct PE inputs” for 2016.

·Flow cytometry misvalued code

CMS identified flow cytometry code 88185 (technical component for each additional marker after the first) as being potentially misvalued. Despite this, the ASCP notes CMS is proposing to increase reimbursement for code 88185 by 5.3% in its proposed rule.

·Hospital outpatient rate cap proposal

Last year CMS proposed to cap reimbursement for the technical component of tests on the PFS at the much lower hospital outpatient rate, but then  postponed the implementation of that policy. CMS revisits that proposal in the 2015 Proposed Rule (pages 60-66), but only to say it is scrapping it. They were persuaded [by the comments submitted] that the comparison of OPPS (or ASC) payment amounts to PFS payment amounts for particular procedures is not the most appropriate or effective approach to ensuring that that PFS payment rates are based on accurate cost assumptions.

·Physician Quality Reporting System (PQRS)

Three measures specific to pathology have been added for 2015 reporting (pages 319-320 of the Proposed Rule)

·Streamlining of Local Coverage Determination (LCD) process

CMS announced its intention to establish a streamlined process that Medicare Administrative Contractors (MACs) “must follow when developing clinical diagnostic laboratory test LCDs and encouraging MACs to collaborate on such policies across jurisdictions.”

·Overall impact

The College of American Pathologists (CAP) estimates overall payment to pathologists will increase 1%, and independent laboratories will see a 3% bump compared to 2014. The CAP’s impact table can be found here.

Source: https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-15948.pdf